Do ya gotta keep your bed up? Reviewing the right positioning for reflux management

Title: Head of bed elevation to relieve gastroesophageal reflux symptoms: a systematic review
Authors: Albarqouni, Moynihan, Clark, Scott, Duggan, & Del Mar
Journal: BMC Family Practice
Year of Publication: 2021
Design Type: Systematic Review
Purpose: The aim of this study was to do a systematic review of controlled trials that evaluated the effect of head-of-bed elevation or positioning on relieving GORD symptoms among adults
Population: adults with symptoms suggestive of GORD/GERD symptoms of any severity and as diagnosed in each study
Inclusion criteria: RCTs/non-RCT studies evaluating change of head-of-bed position interventions including 1) head-of-bed elevation (wedge pillow or bed blocks), 2) left lateral sleeping position, or 3) both; studies with these interventions together with co-interventions (PPIs) as long as effect of intervention could be isolated; studies with control (flat position or right lateral sleep position); abstract only publications if adequate information was reported; any language or timeframe
Exclusion criteria: before/after studies with no control groups; observational studies; review articles

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With the holiday season upon us quicker than an NPO patient downing 3 oz of water, what better topic to think about than gastroesophageal reflux?!

While some make the case it might not necessarily be directly within our wheelhouse, it’s definitely a topic that’s frequently discussed and encountered enough by our patients, peers, and professional colleagues to make it relevant.

So what do we need to know? Well to be frank, lots🥴. But since we can’t diagnose nor prescribe, this specific article took a stab at investigating other common recommendations and strategies to help manage reflux symptoms in much simpler ways and that we’ve already been doing!

Who knows, you might even find yourself holding your head a bit higher after reading!😄

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• Only got a sec?
  • Raising the head of the bed, either by block or wedge, could be beneficial in reducing reflux-like symptoms and potentially reduce reliance on prescriptions on a patient-by-patient basis
• Only got a minute?
  • “Overall, the results suggest that head-of-bed elevation may have a beneficial effect on relieving gastroesophageal reflux symptoms. These results are supported by the observed improvement in physiological intra-oesophageal pH measurements.“
  • “Methodological and reporting limitations in available literature preclude confident conclusions about the effect of head of bed elevation in relieving gastroesophageal symptoms. However, head of bed elevation could be still considered as a cheap, relatively safe, and promising alternative to drug interventions with unfavorable safety profiles.“
  • “Given the need to reduce the overuse of unnecessary medicines – with an unfavorable safety profile– clinicians must be able to offer evidence-based non-pharmacological alternatives for treating these extremely common symptoms.“
• Got more time? Keep Reading!!

Since our field is riddled in acronyms, let’s decode first:

“Proton Pump inhibitors (PPIs) are usually prescribed to treat common upper gastrointestinal symptoms often diagnosed as Gastroesophageal Reflux Disease, GORD (aka GERD or reflux disease).” p.1

But like with any medication, there can always be some adverse impacts, especially when the spectrum of how much, why, and when these medications are recommended can vary as much as pasta options, “with estimates that between one-quarter and two-thirds of patients may be taking them inappropriately.”

Emerging evidence has also brought to light that long-term use may result in increased risks for fractures, pneumonia, and additional infections. With some professionals first advising alternative methods to reduce or prevent gastrointestinal symptoms (e.g. heartburn, dyspepsia, and regurgitation) such as reduction/elimination of food sources, ending unhealthy habits like smoking/overweight, or improving cognizance of behaviors like late-night snacking, an easily overlooked intervention may be as simple as changing post-meal positioning to avoid or reduce the use of PPIs.

Unfortunately, while this specific yet easy-to-implement option has been shown to “reduce the oesophageal exposure to stomach acid and increase the clearance of acid from the oesophagus,” there hasn’t been a lot of comprehensive evidence for an adequate overview on this intervention to come to a general consensus (hmm…sounds similar to our many oropharyngeal interventions/exercises🤔).

The authors made sure they were pretty clear in what they were looking for by not only including obvious changes but also quantitative/objective results:

• Primary outcome: changes in GORD symptoms and use of PPIs
• Secondary outcome: physiological measurements of intra-oesophageal pH (e.g. acid exposure/reflux episodes), disease progression, and adverse events

So after scouring multiple journals from the beginning of time (up to the very specific date of June 23, 2020?), lots of discussions and consensus, and even the use of similar tools to those shared within Resources for further appraisal, they eventually went from a total of 1,206 to….5 studies in their narrative synthesis. Surprisingly, they were all from a variety of locations (U.K., U.S., Taiwan, and Columbia) as well as timeframes (1970s/1980s, 2019/2020).

But before we move on looking at each of these five’s quality and what they did or didn’t say, the authors actually provided us some great examples of even more similar Resources in their Appendix ^{(link found at the end of article (Supplementary Information).}

by sharing their actual ‘Search Strategy” and their search strings for all databases! Ok, I get that may not sound nearly as fun as someone doing all the work for you while you sit enjoying a pizza, but it can be added to your starter pack for when you have a specific topic in mind you want to search and investigate a bit more on🤓. For another example, check out and download your own Search String Resource!

Some more ‘lil helpful lessons I learned for the future to help me search more in-depth about a topic or relevant question:

1. Forward/Backward citation searches

Forward Citation Search: A search to find all of the articles that cite back to a specific article

Backward Citation Search: A search to find all of the cited references in a single article

As I learned, these can be helpful to learn more broadly about a topic (like the history or origin from when it came about, e.g. aspiration pneumonia) or to get a bunch of related information and evidence more quickly. (check out the first link above for a how-to guide on different ways to search!)

2. Assessing risk of bias

There are a bunch of ways a study, data, or researcher can have bias. The authors used a tool that turns out is pretty similar to the one already shared for you in Resources to help us, clinicians, be able to identify different biases (the link above also gives you examples of potential impacts and easy questions to ask when reading studies😉).

Alright I know that might’ve been a bit of a snooze-fest for some, so we’ll keep it moving😄. . .

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Apparently, because other fields have the same problem we do with not having enough similar studies comparing similar data for similar outcomes (basically a grab-bag for all research), it should be no surprise that a meta-analysis couldn’t be completed to really see big significant impacts🙄. Luckily, we’re still given some good descriptions to start with for the top 5 studies:

• 4 cross-over trials
  • Crossover trials are trials in which participants do not only receive one intervention, but multiple, and the effect of the interventions are measured on the same individuals

• 1 factorial RCT
  • A factorial randomized controlled trial ( RCT ) is a specific type of RCT. It lets you carry out 2 or more comparisons at the same time

While all studies had participants with gastroesophageal symptoms (and one with prior esophageal cancer/esophagectomy), they varied only slightly in their interventions:

• 2 used ‘bed blocks‘ only (20 cm blocks under the legs of the head of the bed)
• 1 used ‘sleeping wedge‘ only (sleeping on a 20 cm wedge-shaped pillow)
• 2 used both interventions separately
• Control groups= lying flat position or a standard pillow(s) or compared to PPI use
• NO studies looked at left lateral sleep positioning

Remember those outcomes? When all 5 studies were grouped and compared together, the results might take you for a spin…

Gastroesophageal reflux symptoms

“All the four (of the five included) studies that we identified evaluating the impact of head of bed elevation on patient-reported gastroesophageal reflux symptoms found an improvement among participants in the head-of-bed elevation intervention arm.” p.4

These results from all the studies were based on participant reports and various surveys (i.e. Reflux Disease Questionnaire Score & modified Dysfunction after Upper Gastrointestinal Surgery scale)

and while the one factorial RCT that compared the effect of ranitidine+head-of-bed elevation found “no statistically significant difference in overall improvement of symptoms reported by adults receiving the head-of-bed elevation only compared to adults receiving ranitidine only,” a crossover study looking at participants 2-weeks post-esophagectomy did find “statistically significant improvement in GORD symptoms in head-of-bed elevation compared to the control group.” 

Other findings showed improvement in reduced reported reflux symptoms from participants in the head-of-bed groups compared to control groups. While that might be anywhere from halfway through the night, to the next day, to 2-6 weeks post-intervention, will be left up for us and our patients to decide it’s overall impact🤔…

Intra-oesophageal pH measurement

While only 2 studies out of the 5 actually used these measures, these quantitative findings can give us more confidence since these tests can have a more objective way of telling you your pH levels than your gut feelings (pun intended)😉.

When it came to:

• 1 study found NO significance between bed wedge or block vs control group
• 1 study found significant reduction in bed block only (none for wedge) vs control group

• BOTH studies found significant reduction for elevated head group vs control
  • 1 found significance for bed wedge and block
  • 1 found significance for bed block only

•  No studies found any significant difference between any of bed block/wedge groups vs control

If that was as confusing to you as it was to me, no worries my friend🥴! Basically, while bed blocks may look like they come out on top, we can’t really say which is better ( blocks vs wedge) since it’ll likely depend on what you’re looking at and measuring (along with personal preferences). Overall though, at least both seemed to do the trick when it came to objective acid prevention measures compared to plank position😎.

Patient Preferences

Because we live in a consumer-driven society, I’m sure many are curious if there was any preference for bed wedge vs bed block vs natural flat sleeping..

Turns out when compared to the control of laying flat on a bed: One of the RCTs showed “63% participants preferred some form of head-of-bed elevation” while another revealed, “60% preferred ‘bed blocks’, 33% preferred ‘bed wedge,’ and 7% preferred neither.“

Curious if anything bad happened with all these position changes??

Shockingly enough, 2 studies bravely reported some incidental findings that included “largely minor adverse events” such as bed slipping, unsteadiness, varicose vein pain, musculoskeletal pain, sexual activity interference that all resolved just fine with no subjects dropping out. Hooray for sticking it out! (Or, I guess sticking your head up for the study😏)

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As the saying goes,

Even though the systematic review gave its best effort and actually did quite well given the limited options, we can never gloss over the dirty details that lie in all the limitations.

While the authors of the article only seemed to mention a few limitations from the small pool of included studies such as all had a small sample size (what else is new🙄), short durations for intervention trials (which were limited to either part of a night, full night, or 6 weeks), along with variable outcomes measures, just like a Hidden Pictures book, you might take a few minutes to really analyze their simple Tables/Figures to spot some more.

For starters, other than one study stating ‘endoscopic evidence of erosive esophagitis,” because there really is no mention if the other studies just weren’t detailed enough, it’s really not that clear to me just how all participants were diagnosed with GORD/GERD management or if this was even addressed? Therefore, I’m kind of left assuming it’s either by a) the reported symptoms, b) the use of PPIs/prescriptions or c) maybe participation in other studies or additional co-morbidities? This is all ok, but you know what they say when you assume, so better to just state the lack of descriptions if that’s the case, especially if there’s no mention if the authors hadn’t attempted to contact the original authors from the studies.

A last little lingering thought left in my mind was more food for thought on just how all these participants were recruited and also just who were these individuals? It’s pretty obvious that we are looking at the right population given across-the-board hospital recruiting, BUT I still would’ve liked to know if there were maybe any trends in this selected population like in age ranges (49-74 years), or because all participants were recruited from hospital settings, or even between differences in mild vs severe reflux symptoms?? Obviously, some of this may be simple enough to figure out or harder for me to ever understand🙃, but alas, I can’t turn my busy brain off nor would I want to since this is what leads to deeper critical thinking versus simply taking things for what they say!

Fortunately, the article’s authors do share a creatively color-coded graph to decipher the overall risk of bias and mention:

“All five included studies were judged to be at high risk in two or more of the domains of risk of bias. All five studies were judged to be at high risk of performance bias (either blinding of patients and personnel or outcome assessors), and four at high or unclear risk for selection bias (either random sequence generation or allocation concealment).” p.4

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So, what’s the meaning of it all?

I’ll let many of you come to your own final conclusions, but something I can’t argue is who doesn’t want to reduce the number of medications someone has to take?!? If recommending something as easy as lifting the head at night can have some kind of positive impact and doesn’t result in actual serious negative effects, then why not?!??

While the authors may be a bit more inconsistent by stating the established ‘confirmation’ for bed elevation, just as everything else in our field, trial-and-error and patient-specific recommendations are gonna be here to stay for all, even across professions.

Do we know this is a surefire solution?

Nope!🥴

Do we have the best evidence available with great, consistent methodologies to at least give us some indications that this is better than prescriptions?

Not exactly.🤷‍♀️

But as clinicians, can we feel okay recommending such a simple, common way to possibly alleviate some discomfort when it comes to reflux?

The results do seem to suggest this as well, especially given the fact that “Importantly we did not find evidence of no benefit from this approach, but rather we found low-quality evidence of benefit.“

Low evidence or no evidence, you can take your pick. And that’s just what we do with our patients! We pick and choose what intervention possibilities seem appropriate for each patient. So now we can go out there, hold our heads a bit higher, and let our patients know they can try doing the same.😊

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Article Referenced: [FREE ACCESS]

Albarqouni, L., Moynihan, R., Clark, J., Scott, A., Duggan, A., & Del Mar, C. (2021). Head of bed elevation to relieve gastroesophageal reflux symptoms: a systematic review. BMC Family Practice, 22(1). doi: 10.1186/s12875-021-01369-0